Analysis Stability The MelinaKeithII had a starboard list as it took water over the bottom edge of the hauling door. This had an adverse effect on the stability because water accumulated to such an extent that the pumps could not manage it and the accumulation of water on the starboard side further exacerbated the situation; the added weight of shipped water raised the final centre of gravity; the freeing ports were welded shut, and this impeded the washed water from clearing the deck. The virtual centre of gravity was also raised due to free-surface effect of water on deck. Lifesaving Equipment Liferafts Although both inflatable liferafts were fitted with hydrostatic releases and one was reported to have been cut free, neither came to the surface. The devices are designed to activate when submerged to a depth of more than 4m, and should have been at that depth when the vessel was upside down; however, the release mechanisms may not have activated. Taking into account the length of time the vessel remained afloat after capsizing, water may have entered through the drainage holes, filling the rigid canister, until it lost residual buoyancy. Nevertheless, at least one of the liferafts should have risen to the surface. Although crew members attempted to cut the port liferaft free, they were unable to lift it from the cradle. Because the vessel sank, the precise reason for the liferafts not surfacing could not be determined. However, the arrangement of the railing on the monkey island would restrict the port liferaft from floating free with the vessel listed to starboard. In small fishing vessels, it is common for liferafts to be positioned on top of the wheelhouse where they are unlikely to interfere with fishing operations. In such circumstances, crew members must make their way to the top of the wheelhouse to release a liferaft from its cradle. While the size of small fishing vessels, their physical limitations, and the need to keep liferafts clear of fishing operations present challenges for liferaft stowage, options are available. These include a cutout in the railing that allows the liferaft to pass through; a cradle design allowing the ready launch of the liferaft clear of the vessel's side; the provision of a mechanical launching mechanism with minimum maintenance requirements; and the provision of a physical barrier to prevent fouling of the rigging during launch. Although the common positioning of liferafts hampers rapid deployment in an emergency, depriving the crew of valuable lifesaving equipment, TC does not provide guidance to its inspectors to help them determine the optimum positioning of the liferaft on board. Personal Flotation Devices Due to the rapid escalation of emergencies leading to the abandonment of small fishing vessels, crew members have little time to don PFDs. Because lifejackets (required by regulations) are cumbersome, they are not worn and their bulk presents a hazard with respect to their entanglement in fishing gear. Personal full-length lifesaving devices that are practical to don, together with a need-to-wear requirement, could help mitigate some of the risks, thereby increasing chances of survival in cold, Canadian climatic conditions. Although proposed reforms to the Canada Shipping Act address the use of PFDs in an open boat or while on deck, and although TCstrongly encourages their use, the current draft states only that PFDs should be readily available. Without a need-to-wear component, fishers will continue to be at high risk during abandonment. Distress Alerting The capsizing occurred suddenly, leaving the skipper and crew little time to prepare. When the skipper realized that there was a problem, he left the deck for the wheelhouse to study the video monitors, but knew that the vessel was in danger by the time he got there. After retrieving immersion suits, he had little time to activate the distress feature on the DSC radio or the Sat-C system; hence, no additional distress alerts were sent. The EPIRB signal was thus the only indication that the vessel was in trouble. However, an EPIRB signal that is received in conjunction with another indicator of distress - such as a DSC alert, Inmarsat-C alert, or verbal Mayday, VHF (satellite telephone call or cellular telephone call) - would provide prompt validation of the distress. Search and Rescue At the time of the occurrence, there was only one SAR coordinator on duty. Additional support was requested once it was apparent that this was a real emergency. In the absence of accurate information available from the Canadian Beacon Registry, valuable time was lost in ensuring that the emergency was real. One potential aid for SAR coordinators is the VMS. In this occurrence, the SAR coordinator did not check the positional data for the MelinaKeithII until just before obtaining a composite satellite position. Although SAR coordinators had previously used the VMS to identify fishing vessels in the vicinity of a distressed vessel, and by another coordinator to verify the location of a distressed vessel, the system had never been used by this duty SAR coordinator as a primary means to identify a distressed vessel's location. The quality of information required by the Canadian Beacon Registry, in conjunction with the VMS not being used to advantage at an early stage, resulted in the loss of valuable time to validate the distress. Search and Rescue Response Although the vessel capsized a half hour before the end of regular Department of National Defence (DND) working hours, for which DND has a 30-minute response standard, tasking of SAR air resources occurred after working hours. As such, the primary SAR air resources at Canadian Forces Base Gander were operating on the quiet hour standard of a two-hour (maximum) response time. The response helicopter (R908) departed for the scene 80minutes after being tasked and it is not possible to determine the impact of this on the eventual outcome. In 1992, the Auditor General of Canada, after conducting a review6 of the national SAR program, noted that neither the CCG nor DND had established service standards covering all time elements of SAR response. The Auditor General also noted that, although service standards need to be developed, response times may have to be longer for less-populated areas in which there are few incidents and where resources may be located some distance away. The Auditor General's 1994follow-up on action taken in response to the 1992observations and recommendations noted that the CCG and DND have neither established nor used time-based search and rescue service standards to plan for resources and indicate to the public the expected response standards for search and rescue resources. They continue to believe that time-based service standards would not be beneficial or practical because they do not provide a true indication of the effectiveness of the search and rescue program.7 In 1999, the NSS conducted a review of SAR response services,8 noting that, although the DND prescribes 30-minute and two-hour response capabilities for working hours and quiet hours respectively, the CCG nonetheless maintains a maximum 30-minute response standard 24/7for primary SAR vessels. The report also noted that resource availability determines DND's SAR standby position and that the 30-minute standard during working hours does not always coincide with the days or time of peak SAR activity. This issue was reviewed again after 1999as part of the Strategic Transition Initiative Project, which was completed by the NSS in2002. In December2004, the Interdepartmental Committee on Search and Rescue approved the objectives and principles to be used in the development of specific levels of service for each federal department in the SAR program with the understanding that each SAR partner would further refine the level of service relative to their operations. A TSB review of reported marine occurrences involving SAR air response between 1995and 2005indicates that at least 60percent of occurrences took place during working hours. The NSS report concluded that a lack of strategic management within the SAR program has resulted in each department developing standby postures in isolation, without consultation with other SAR departments. As a result, there is no common rationale driving standby postures. The report recommended that ''the standby postures of primary SAR resources should be determined primarily through an analysis of demand for services. No further review of SAR readiness and standby position has been conducted by the NSS since 1999. Although local DND SAR commanders have the discretion to realign SAR standby periods to coincide with periods of greatest SAR activity, DND policy limits the 30-minute standby position to 40hours per week, indicating that resource availability continues to be the primary factor in determining SAR response standards. Onboard Operational Safety During vessel operations, the skipper is responsible for personnel and equipment safety. In this occurrence, there were practices in which risks were not fully recognized. These included the following: Fishing continued in choppy seas with a near-full hold, despite a starboard list. Crew members were not made aware of the location of immersion suits, did not regularly participate in emergency drills, and were unfamiliar with the liferafts and the hydrostatic units. Despite the regulatory requirement, there was no qualified mate to help coordinate an emergency response or abandonment, or help with day-to-day activities and decision making. The crew was not instructed to proceed to emergency stations or don immersion suits. Such unsafe practices are common on small fishing vessels. This is due to a combination of reasons including the lack of a safety culture, perception or appreciation of risks, and a lack of awareness. For instance, an individual's perception that the probability of an accident is low is increased with each successful voyage completed. As an individual becomes more comfortable, the threshold of risk is increased and can lead to more unsafe practices,9 thus placing the vessel and crew at a greater risk. The MelinaKeithII was fishing in choppy seas with a near-full hold, a starboard list, and beam to the wind. When the vessel's pumps could not keep up with the water ingress that flowed in over the hauling door, the vessel heeled over to starboard and capsized. The freeing ports were welded shut, impeding the shipped water from clearing the deck. The cumulative effect of the loading condition and the accumulation of water on deck in the prevailing conditions resulted in the loss of transverse stability.Findings as to Causes and Contributing Factors The MelinaKeithII was fishing in choppy seas with a near-full hold, a starboard list, and beam to the wind. When the vessel's pumps could not keep up with the water ingress that flowed in over the hauling door, the vessel heeled over to starboard and capsized. The freeing ports were welded shut, impeding the shipped water from clearing the deck. The cumulative effect of the loading condition and the accumulation of water on deck in the prevailing conditions resulted in the loss of transverse stability. The quality of information required for the Canadian Beacon Registry is not conducive to saving valuable time to validate distress. Although the common positioning of liferafts hampers rapid deployment in an emergency, depriving the crew of valuable lifesaving equipment, Transport Canada does not provide guidance to its inspectors to help them determine the optimum positioning of the liferaft on board. Neither the current regulations nor the proposed regulatory requirement for the carriage of personal flotation devices (PFDs) and lifejackets address the risk posed by fishers not wearing the equipment while working on deck. The MelinaKeithII underwent major modifications that adversely affected its stability. TCdid not request a stability assessment following the 2004quadrennial inspection, nor did the owner. The unsafe practice of operating without a certificated mate on board left the skipper to act on his own with no qualified watch relief and with no other designated person to assist in sending distress alerts or coordinate abandoning the vessel.Findings as to Risk The quality of information required for the Canadian Beacon Registry is not conducive to saving valuable time to validate distress. Although the common positioning of liferafts hampers rapid deployment in an emergency, depriving the crew of valuable lifesaving equipment, Transport Canada does not provide guidance to its inspectors to help them determine the optimum positioning of the liferaft on board. Neither the current regulations nor the proposed regulatory requirement for the carriage of personal flotation devices (PFDs) and lifejackets address the risk posed by fishers not wearing the equipment while working on deck. The MelinaKeithII underwent major modifications that adversely affected its stability. TCdid not request a stability assessment following the 2004quadrennial inspection, nor did the owner. The unsafe practice of operating without a certificated mate on board left the skipper to act on his own with no qualified watch relief and with no other designated person to assist in sending distress alerts or coordinate abandoning the vessel. The Vessel Monitoring System was not used in a timely manner to confirm the vessel's location.Other Finding The Vessel Monitoring System was not used in a timely manner to confirm the vessel's location. Safety Action Action Taken Beacon Registration In April 2006, the TSB issued Marine Safety Advisory (MSA)06/06 addressed to the National Search and Rescue Secretariat (NSS) regarding the adequacy of EPIRB registration forms and the associated emergency contact numbers. The MSA noted that, given that search and rescue (SAR) coordinators are under a heavy workload and have previously had difficulty contacting fishing vessel owners/operators via contact numbers, the EPIRB registration form may require updating or revision. The NSS responded that it was in the process of updating the Canadian Beacon Registry, that it was considering the TSB suggestions, and that it would implement them in the overall project plan. The NSS also assured the TSB that it will continue to maintain accurate and useful information in the Canadian Beacon Registry and work with the regulating agencies to promote registration and maintenance of accurate information. Effective August 2006, the registry was amended as part of the Canadian Beacon Registry Update project. The current form now includes two clearly identified sections: Owner Contact Information and Required Emergency Contact Information. The Emergency Contact section calls for the identification of primary and secondary24/7 contacts, with the explanatory warning: Do not include owner, unless not aboard. Stability Over the years, the Board has expressed concern that the lack of stability assessments of small fishing vessels compromises their safe operation. The Board has made two recommendations (M03-05 and M03-06, issued in November2003) to Transport Canada (TC), calling for some form of stability assessment/verification for new and existing inspected small fishing vessels. In2005, following the accident involving the Ryan'sCommander, the Board was concerned that, in the absence of meaningful action to address past recommendations, fishers continued to be placed at undue risk. It therefore made another recommendation (M05-04) urging TC to immediately implement recommendations M03-05 and M03-06. In response to Recommendation M05-04, TCindicated that, in advance of the new Fishing Vessel Safety Regulations, it had established an interim policy for determining, based on a list of risk factors, whether a small inspected fishing vessel requires a stability booklet. This interim measure provides important additional information for the master and took effect 07March2006. TC has issued Ship Safety Bulletin (SSB) 04/2006, entitled Safety of Small Fishing Vessels: Information to Owners/Masters about Stability Booklets. The bulletin outlines the process that vessel owners and operators must follow to determine if their vessel requires a stability booklet and how to obtain one. The bulletin applies to all owners and operators of fishing vessels, new and existing, that are between 15and 150gross tons and less than 24.4m in length. The interim actions and measures taken by TC will substantially reduce the risks associated with safety deficiencies identified in recommendations M03-05 and M03-06. The response was therefore assessed as Fully Satisfactory. Electronic Position Reporting Following the capsizing and sinking of the MelinaKeithII, the superintendent of Maritime Rescue Sub-Centre (MRSC) for the Canadian Coast Guard (CCG) Newfoundland and Labrador Region circulated a memo to SAR coordinators regarding reporting systems such as the Information System on Marine Navigation (INNAV), the Automated Information System, and the Vessel Monitoring System (VMS). The memo pointed out that, while these systems are not regulated for the provision of maritime distress alerting, they can be useful tools in the handling of maritime SAR incidents that involve unlocated distress alerts and 406MHz EPIRBs, or for identifying resources that may provide assistance. The memo instructed SAR coordinators to use these resources at their earliest opportunity so as to ensure effective SARresponse. Search and Rescue Reviews As a result of the MelinaKeithII accident, two reviews were conducted, one regarding SAR operations, the other dealing with standards. These resulted in 18and 17recommendations, respectively. Many have since been implemented, and the remainder are in progress. Included in these recommendations are the following: SAR coordinator refresher and continuous training on electronic information gathering systems such as VMS and Cospas/Sarsat operation (in progress); review the air SAR standby posture (in progress); all emergency position-indicating radio beacons (EPIRBs) should be equipped with global positioning system (GPS) (in progress); duty SAR coordinators to be mindful of the standby posture of Department of National Defence (DND) primary resources respecting the change from 30 minutes to two-hour response times at 1600local time (completed); and updating of the National Search and Rescue Manual(in progress). Safety Concern The issue of positioning of fishing vessel liferafts and the float-free requirements has been addressed several times over recent years. In1993, the CapeAspy10 accident gave rise to Board Recommendation M93-03 that resulted in TCissuing SSB09/93. A TCstudy initiated in March1998 to consider methods of improving the stowage of lifesaving equipment on fishing vessels was never completed. Fishing vessel occurrences involving loss of life11 raised similar issues and eventually led to another SSB(03/01). TC also issued a Small Fishing Vessel Safety Manual (TP10038) in2003, which recommends that liferafts be installed where they can be easily launched, but where they will float free if the ship sinks before launching. In updating its response to Board Recommendation M93-03 in November2006, TCadvised that provisions requiring float-free liferafts will be proposed to be adopted in the Fishing Vessel Safety Regulations and would be similar to those included in the amended Life Saving Equipment Regulations for passenger vessels. The Fishing Vessel Safety Regulations are expected to be finalized in2008. In the interim, TC intends to issue a new SSB addressing the stowage of liferafts and inflatable rescue platforms. This new bulletin will combine the existing points contained in SSBs09/1993 and 03/2001 and will also have additional information with regard to the optimum positioning of the liferafts. The Board is concerned that, until such time that regulations are put in place and fishing vessel liferafts are positioned optimally and arranged to float free in the event of the vessel sinking, crew members continue to be at risk in such circumstances.